Heart Health: Do the New Statin Guidelines Affect You?
By: Darria Long Gillespie, MD, MBA
New guidelines for prescribing statins released by The American College of Cardiology (ACC) and the American Heart Association (AHA) this week have caused debate -- and some consternation -- within the medical community.
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That's because the guidelines do an about-face from what used to be considered the gold standard for treating patients with high cholesterol: prescribe a statin and monitor "bad" LDL cholesterol levels through regular blood tests. The goal was to reach an LDL of less than 100 (or less than 70 for some). The new guidelines not only advise doctors not to prescribe statins based on cholesterol levels alone, they don't set any LDL target levels when the drug is prescribed.
Instead, doctors are advised to prescribe statin regimens based on an individual patient's medical conditions and -- in some cases -- via a new online risk calculator that would take other factors, besides cholesterol, into consideration before prescribing a statin to a patient, incorporating gender, age and blood pressure. (Find the new calculator at my.americanheart.org)
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Currently, statins are prescribed for 25% of people in the U.S. over 40. With the new guidelines, a large number of people who are not taking statins may now be advised to do so. However, some experts fear that the increased usage of statins may distract some patients from the importance of diet and lifestyle. "I fear that under the new guidelines, many people who would otherwise be able to manage their cardiovascular risk through non-pharmaceutical means will be pressured to take a medication which may not benefit them and could have harmful side effects," says, Dr. Mehmet Oz, MD,director of the Cardiovascular Institute and Complementary Medicine Program at New York Presbyterian Hospital and host of The Doctor Oz Show.
Who now needs treatment?
1. People who already have had a stroke or heart attack should be on a "high intensity" (high intensity = goal of reducing LDL by 50%) statin regimen
2. People with LDL greater than or equal to 190 mg/dl would also need the "high intensity" regimen.
3. People ages 40-75 with diabetes may need to be on either moderate or high-intensity therapy, depending on their risk score.
4. People ages 40-75 with no cardiovascular disease or diabetes, but with an estimated 10-year risk greater than or equal to 7.5%.
While this represents a major departure from prior recommendations, the AHA and ACC are not the only ones recommending them -- the Department of Veterans Administration incorporated similar guidelines last year.
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Still, questions remain. Some experts argue that focus on lowering a patient's LDL below a certain number is beneficial, especially in people with certain genetic predispositions to cardiac disease. There are also questions about how well the 10-year risk factor calculator works for younger patients. According to the new calculator, someone under the age of 40 with a moderately high LDL (less than 190) but without other risk factors may not need statins. Even the authors of the paper cautioned here, however, noting that in younger people, it may make sense to look at longer-term risk, such as over the next 20-30 years, instead of just short-term.
What about side effects? Like any medication, statins come with their own side effects. "Their potential side effects include muscle pain, muscle damage, an increased risk of diabetes (particularly in women), digestive problems such as nausea, diarrhea and constipation, memory loss or confusion (though this is being hotly debated) and, rarely, serious liver damage," says Dr. Oz.
Lifestyle Still Matters First and foremost, the study authors emphasized the importance of a healthy lifestyle and diet -- both before and during treatment with statins. They recommended the DASH diet or AHA diet, restricting saturated and trans fats, and reducing sodium. Taking a statin (or any other prescribed medication) does not ever replace having a healthy lifestyle, healthy nutrition, and regular activity. Weight loss and good nutrition can significantly impact a patient's risk for diabetes, high cholesterol, and heart disease and should always be addressed before starting any medication and continued after the medication has been begun.
If you're on a statin, you'll need to have a conversation with your doctor to decide if you want to continue. Things that were not incorporated into the guidelines (but should be considered individually with your doctor) include family history of premature heart disease in a first-degree relative, high CRP, coronary calcium score, and the ankle-brachial index.
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